Glycosaminoglycans, uric acid and calcium oxalate urolithiasis

Comparison of the metabolic profile of mixed calcium oxalate/uric acid stone formers to that of pure calcium oxalate and pure uric acid stone formers

OBJECTIVE

To compare the metabolic profile of patients who form mixed calcium oxalate (CaOx)/uric acid (UA) stones to those of pure CaOx and pure UA stone formers.

METHODS

We performed a retrospective review of 232 patients, with both stone composition analysis and 24-hour urine collection, seen between March 2002 and April 2012. Analysis of 24-hour urine constituents across the 3 stone groups (pure UA, pure CaOx, and mixed CaOx/UA) was performed using univariate analysis of variance and multivariate linear regression models adjusting for clinical and demographic factors and 24-hour urine collection elements.

RESULTS

A total of 27 patients (11.6%) had mixed CaOx/UA, 122 (52.6%) had pure CaOx, and 83 (35.8%) had pure UA calculi. Univariate analysis demonstrated significant differences between mixed CaOx/UA patients and pure CaOx patients for urine pH (mixed, 5.63 ± 0.49 vs pure, CaOx 5.93 ± 0.51; P = .009) and supersaturation (SS) UA (mixed, 1.84 ± 1.09 vs pure, CaOx 1.26 ± 0.93; P = .01), and a significant difference between mixed CaOx/UA patients and pure UA patients for SS CaOx (mixed, 7.18 ± 4.23 vs pure, UA 4.90 ± 2.96; P = .005). Multivariate analysis demonstrated that mixed CaOx/UA patients had no significant difference in SS CaOx as compared with pure CaOx patients (difference, -0.27; P = .66), whereas at the same time had no significant difference in SS UA as compared with pure UA patients (-0.07; P = .69).

CONCLUSION

The metabolic profile of patients who form mixed CaOx/UA stones demonstrates abnormalities that promote both CaOx and UA stone formation. Dietary and medical management for this group of patients should address treatment of both defects.

Uric acid as inducer of calcium oxalate crystal development

OBJECTIVE

This paper deals with the mechanism by which uric acid affects calcium oxalate crystallization and the role of crystallization inhibitors in this process.

MATERIAL AND METHODS

Pure uric acid crystals and fragments of uric acid renal calculi were used to induce calcium oxalate crystal formation and development. These studies were performed in flow systems, using synthetic urine and similar conditions to those found in real renal situations. The type and size of the developed crystals were evaluated by scanning electron microscopy and the amount of calcium oxalate crystallized was quantitated by means of inductively coupled plasma atomic emission spectroscopy.

RESULTS

The presence of uric acid crystals in a flow system provoked calcium oxalate monohydrate (COM) crystallization at a rate of 3.3 microg/h/mg uric acid. When uric acid renal calculi fragments were used, the amount of COM crystallized varied between 0.048 and 0.161 microg/h/mg of renal calculi depending on the porosity of the calculus. At particular concentrations (3.03 microM phytate, 28.75 microM pyrophosphate, 40 mg/l chondroitin sulphate) the crystallization inhibitors assayed produced a maximum decrease of approximately 50% in the amount of COM crystallized on uric acid crystals. Mucin (a glycoprotein) caused only slight effects.

CONCLUSION

Uric acid crystals can clearly induce the development of COM crystals on them through a heterogeneous nucleation process and some crystallization inhibitors can notably delay such a process.

Physico-chemical alterations of urine in experimental hyperoxaluria: a biochemical approach with fucoidan

Urinary supersaturation-induced crystal formation has been attributed as one of the key factor for the pathogenesis/progression of lithogenesis. This study was aimed at investigating whether fucoidan, a naturally occurring sulfated glycosaminoglycan, could ameliorate the biochemical changes in urine induced by stone formation. Two groups of male albino Wistar rats (120+/-20 g) received 0.75% ethylene glycol (EG) for 28 days to induce hyperoxaluria, and one of them received sulfated polysaccharides (fucoidan from Fucus vesiculosus, 5 mg kg(-1), s.c.), commencing from the 8(th) day of the experimental period. One group was maintained as normal control group and another group served as drug control, which received sulfated polysaccharides. The urine collected from all the groups was analysed for changes in pH, volume, oxalate, calcium, phosphorus, uric acid, magnesium, citric acid and glycosaminoglycans. Urinary crystals were analysed with a light microscope. Renal tissues were studied under polarized light for deposition of crystals and also analysed for their oxalate and calcium content. The changes in extracellular matrix on crystal deposition were also evaluated. The urinary pH and volume were altered in rats treated with EG along with an increase in weight of the kidney. Further, administration of EG to rats increased the supersaturation of urine by escalating the levels of the stone-forming constituents, such as oxalate, calcium, phosphorus and uric acid, which was completely restored by fucoidan treatment. The decrease in the inhibitors, like citrate, magnesium and glycosaminoglycans, in urine was prevented by the co-treatment with fucoidan. In hyperoxaluric rats, there was an increased excretion of calcium oxalate monohydrate crystals in urine along with crystal deposition in renal tissues; this was prevented by fucoidan treatment. Fucoidan administration reversed even the tissue levels of calcium and oxalate. The increased accumulation of collagen and expression of transforming growth factor-beta(1) in hyperoxaluria was normalized on fucoidan administration. These results suggest that the physico-chemical alterations in urine produced during hyperoxaluria can be reversed by fucoidan administration.

Role of uric acid in different types of calcium oxalate renal calculi

AIM

The presence of uric acid in the beginning zone of different types of 'pure' calcium oxalate renal calculi was evaluated with the aim of establishing the degree of participation of uric acid crystals in the formation of such calculi.

METHODS

The core or fragment of different types of 'pure' calcium oxalate renal calculi was detached, pulverized and uric acid extracted. Uric acid was determined using a high-performance liquid chromatography/mass spectrometry method.

RESULTS

In calcium oxalate monohydrate (COM) papillary calculi with a core constituted by COM crystals and organic matter, 0.030+/-0.007% uric acid was found in the core. In COM papillary calculi with a core constituted by hydroxyapatite, 0.031+/-0.008% uric acid was found in the core. In COM unattached calculi (formed in renal cavities) with the core mainly formed by COM crystals and organic matter, 0.24+/-0.09% uric acid was found in the core. In COM unattached calculi with the core formed by uric acid identifiable by scanning electron microscopy (SEM) coupled to X-ray microanalysis, 20.8+/-7.8% uric acid was found in the core. In calcium oxalate dihydrate (COD) unattached calculi containing little amounts of organic matter, 0.012+/-0.004% uric acid was found. In COD unattached calculi containing little amounts of organic matter and hydroxyapatite, 0.0030+/-0.0004% of uric acid was found.

CONCLUSIONS

From these results it can be deduced that uric acid can play an important role as inducer (heterogeneous nucleant) of COM unattached calculi with the core formed by uric acid identifiable by SEM coupled to X-ray microanalysis (these calculi constitute the 1.2% of all calculi) and in COM unattached calculi with the core mainly formed by COM crystals and organic matter (these calculi constitute the 10.8% of all calculi).

Urinary glycosaminoglycans as risk factors for uric acid nephrolithiasis: case control study in a Sardinian genetic isolate

OBJECTIVES

To assess the clinical association between glycosaminoglycan (GAG) excretion and uric acid (UA) nephrolithiasis by measuring urinary GAG levels in a case-control study conducted in a Sardinian genetic isolate. Inhibitors of crystallization such as GAGs seem to be involved in kidney stone formation.

METHODS

Overnight (12-hour) urinary excretion of GAGs, calcium, oxalate, and UA were measured in urine samples from 60 patients who had formed at least one urinary stone (UA or mixed) and 52 healthy controls. The total GAG concentration was measured by a dye-binding assay, and the values were normalized against creatinine to obtain values in micrograms of GAG per milligram creatinine. Statistical analysis was performed using t tests and logistic regression analysis.

RESULTS

No significant difference was found between the two groups with respect to calcium and oxalate concentrations. Nonetheless, stone formers had significantly lower levels of GAGs (29.5 +/- 2.2 versus 36.4 +/- 3.9 microg/mg creatinine, P = 0.003) and greater levels of UA (385.11 +/- 38.2 versus 298.43 +/- 31.4 mg/12 hr, P = 0.0010) than did the normal controls.

CONCLUSIONS

We report that the lower excretion of GAGs in stone formers could impair their inhibitory activity on UA stone formation, and, as a consequence, it may represent a risk factor for this form of urolithiasis.

Evaluation of the effect of triterpenes on urinary risk factors of stone formation in pyridoxine deficient hyperoxaluric rats

Investigations were carried out to evaluate the efficacy of the pentacyclic triterpene, lupeol and its ester, lupeol linoleate, against calcium oxalate urolithiasis in rats. Administration of a pyridoxine deficient diet containing 3% glycollic acid for 21 days led to increased excretion of stone forming constituents such as calcium, oxalate and uric acid. Crystal deposition and subsequent renal tubular damage resulted in increased excretion of the tubular enzymes alkaline phosphatase, lactate dehydrogenase, gamma glutamyl transferase, beta glucuronidase and N-acetyl glucosaminidase along with reduced fibrinolytic enzymes. A reduction in the urinary inhibitory factors magnesium and glycosaminoglycans was also observed. Treatment with lupeol and lupeol linoleate reduced the extent of tubular damage as evidenced from reduced enzymuria and minimized the excretion of stone forming constituents.

Control of urinary risk factors of stones by betulin and lupeol in experimental hyperoxaluria

Urolithiasis, the process of formation of stones in the kidney and the urinary tract, is the major clinical manifestation of hyperoxaluria. Crystal deposition, as indicated by increased stone-forming constituents in urine, such as calcium, oxalate and uric acid, and decreased concentration of inhibitors, such as magnesium and glycosaminoglycans, was observed in pyridoxine-deficient hyperoxaluric rats. Renal tubular damage was indicated by increased excretion of enzymes such as alkaline phosphatase, lactate dehydrogenase, gamma-glutamyl transferase, beta-glucuronidase and N-acetyl glucosaminidase. Fibrinolytic activity was found to be reduced. Administration of pentacyclic triterpenes such as lupeol and its structural analogue betulin to hyperoxaluric rats minimised the tubular damage and reduced the markers of crystal deposition in the kidneys. In this connection, lupeol was found to be more effective than betulin.

Adhesion of uric acid crystals to the surface of renal epithelial cells

Adhesion of microcrystals that nucleate in tubular fluid to the apical surface of renal tubular cells could be a critical step in the formation of kidney stones, 12% of which contain uric acid (UA) either alone or admixed with calcium oxalates or calcium phosphates. UA crystals bind rapidly to monolayer cultures of monkey kidney epithelial cells (BSC-1 line), used to model the surface of the nephron, in a concentration-dependent manner. The urinary glycoproteins osteopontin, nephrocalcin, and Tamm-Horsfall glycoprotein had no effect on binding of UA crystals to the cell surface, whereas other polyanions including specific glycosaminoglycans blocked UA crystal adhesion. Specific polycations also inhibited adhesion of UA crystals and appeared to exert their inhibitory effect by coating cells. However, removal of anionic cell surface molecules with neuraminidase, heparitinase I, or chondroitinase ABC each increased UA crystal binding, and sialic acid-binding lectins had no effect. These observations suggest that hydrogen bonding and hydrophobic interactions play a major role in adhesion of electrostatically neutral UA crystals to renal cells, unlike the interaction of calcium-containing crystals with negatively charged molecules on the apical cell surface via ionic forces. After adhesion to the plasma membrane, subsequent cellular events could contribute to UA crystal retention in the kidney and the development of UA or mixed calcium and UA calculi.

Urinary glycosaminoglycan excretion in healthy and stone-forming children

Both in vivo and in vitro studies suggest that macromolecules excreted in the urine, e.g. glycosaminoglycans (GAGs) may be inhibitors of kidney stone formation. We evaluated urinary GAG excretion in 22 children with calcium oxalate stones [8 with absorptive hypercalciuria, 6 with renal hypercalciuria (RH), 8 with normocalciuria], and in 20 age-matched controls. There was no significant difference between the two groups in the total urinary GAG level. In terms of the various GAG fractions, patients with RH excreted considerably less keratan sulphate and considerably more dermatan sulphate than the other patients and healthy controls. There was no difference between the two groups in condroitin sulphate, heparan sulphate and hyaluronic acid excretion. We conclude that there is no significant correlation between the formation of calcium oxalate stones and urinary GAG excretion.

Effect of Herniaria hirsuta and Agropyron repens on calcium oxalate urolithiasis risk in rats

The effects on the calcium oxalate urolithiasis urinary risk factors of Herniaria hirsuta L. (Carryophyllaceae) and Agropyron repens L. (Gramineae), in herb infusion form, combined with different diets (standard, high glucidic, high protein) have been studied using Wistar rats. From this study it is deduced that the possible effects of the A. repens infusion can not be assigned to any positive effects on the main urolithiasis risk factors. The tentative antilithiasic effects of the H. hirsuta infusion clearly depends on the diet. Thus, a clear increase in the citraturia was only detected when such infusion was administered with the high protein diet.

Urolithiasis and phytotherapy

The effects of seven plants with suspected application to prevent and treat stone kidney formation (Verbena officinalis, Lithospermum officinale, Taraxacum officinale, Equisetum arvense, Arctostaphylos uva-ursi, Arctium lappa and Silene saxifraga) have been studied using female Wistar rats. Variations of the main urolithiasis risk factors (citraturia, calciuria, phosphaturia, pH and diuresis) have been evaluated. It can be concluded that beneficial effects caused by these herb infusions on urolithiasis can be attributed to some disinfectant action, and tentatively to the presence of saponins. Specifically, some solvent action can be postulated with respect to uric stones or heterogeneous uric nucleus, due to the basifying capacity of some herb infusions. Nevertheless, for all the mentioned beneficial effects, more effective and equally innocuous substances are well known.

Studies on calcium oxalate monohydrate crystallization: influence of inhibitors

A simple model to study calcium oxalate monohydrate (COM) crystallization on different substrates is presented and the action of different potential inhibitors is evaluated and discussed. COM heterogeneous nucleation was assayed on solid surfaces as calcium phosphate, mixtures of mucin with calcium phosphate, and wax. In the presence of a non-protected non-renewed solid surface in contact with normal urine, COM crystal formation could be detected at short intervals (3 h). The most active heterogeneous nucleation capacity corresponded to calcium phosphate. In the presence of 10% mucin, owing to the renewal of the surface layer no COM crystal were detected on the pellet's surface. The study of citrate and pentosan polysulphate (a semisynthetic polysaccharide) on COM heterogeneous nucleation demonstrated some important inhibitory effects when concentration increased and time decreased. Maximum effects were selectively manifested on calcium phosphate surfaces. Only phytic acid at adequate concentration exhibited a total inhibitory capacity of COM formation, even during longer intervals (15 h).

Glycosaminoglycans and other sulphated polysaccharides in calculogenesis of urinary stones

Naturally occurring glycosaminoglycans (GAGs) and other, semisynthetic, sulphated polysaccharides are thought to play an important role in urolithiasis. Processes involved in urinary stone formation are crystallization and crystal retention. Oxalate transport and renal tubular cell injury are determining factors in these processes. In this article experimental results concerning the possible mechanisms of action of GAGs and other sulphated polysaccharides are reviewed. GAGs are inhibitors of crystal growth and agglomeration and possibly also of nucleation. They can prevent crystal adherence, correct an abnormal oxalate flux and prevent renal tubular cell damage.